Deep-seated mycosis usually occurred in severe immunocompromised patients and is sometimes fatal. Hence, chronic fungal infection occurred in the patients with mild to moderate immunocompromised status and persists for longer period. Biofilm formation is one of the factors related to persisting infection of Candida spp. Biofilm formation resists to the antifungals in catheter-related Candida infection and selection of appropriate antifungals will be an important key to achieve good outcome. Although azoles possessed excellent antifungal activity against planktonic Candida spp., they show lower activity against biofilm-formed Candida spp. Overexpression of efflux pump of Candida spp. is reported to be involved in lowered activity of azoles. Amphotericin B, liposomal amphotericin B, and micafungin however, are expected to have high antifungal activity against biofilm-formed Candida spp. Recently, Aspergillus is also reported to possess potential of forming biofilm. Biofilm formation of Aspergillus is considered to be related to pathogenesis of chronic pulmonary aspergillosis. General antifungals are not highly active to biofilm-formed Aspergillus as same as Candida, and only amphotericin B and its liposomal formulation are expected to be effective in vitro.
Acinetobacter, which is Gram-negative non-fermentated bacilli, is isolated from natural environment and human body, including skin and gastrointestional tracts of both healthy persons and immunocompromised patients. Acinetobacter can cause bacterial infections, such as blood stream infections and health care-associated pneumonia. The definition of multi-drug resistant (MDR) of Acinetobacter has not been internationally harmonized, however, it is defined when MICs of imipenem, amikacin and ciprofloxacin are 16μg/mL, 32 μg/mL and 4μg/mL or higher, respectively, in Japan. Recently, only a few outbreaks by Acinetobacter have been reported in Japan, while outbreaks by Acinetobacter are more common in Western and Asian countries abroad. We should pay attention and caution on outbreaks by Acinetobacter and spread of drug-resistant Acinetobacter as much as we can.
We bacteriologically and genetically analysed 30 cephalosporin-resistant Escherichia coli strains isolated from specimens from 19 neurology-ward inpatients at our hospital over the 3 years from April 2006 to March 2009, surveying and comparing subjectsʼ backgrounds. Of the 30, 19 (63％) were urine, 6 (20％) sputum, and 3 (10％) blood. We tested extended-spectrum β-lactamase (ESBLs) production, found in all samples. PCR and gene sequencing showed that 25 strains (83％) were CTX-M-14 and 5 (17％) CTX-M-2. Among CTX-M-14 strains, two cluster groups I and II, were obtained using pulsed-field gel electrophoresis (PFGE). Cluster group I in particular, continued to be detected for 18 months in the same hospital room. The detection rate was high at 13 (68％) in subjects with urinary catheters and morbidity was high in those with a history of cerebrovascular disease, diabetes, and hypertension. Our findings suggest that genetically identical strains may become established and spread in hospitals possibly due to inadequate contact prevention, subjectsʼ immune status, and risk factor existence.
Nalidixic acid (NA)-resistant and extended-spectrum β-lactamase (ESBL)-producing Salmonella sp. isolates from human specimens are associated with clinical failure or delayed response in subjects treated with fluoroquinolone or third-generation cephalosporins. We studied drug susceptibility in 604 Salmonella enterica isolates from human feces in 2007. Of these, 39 (6.5％) were resistat to NA. Of these, 46％ were resistant to two or more drugs and 2％ susceptible to NA were resistant to multiple drugs (p＜0.001). Three ESBL-producing Salmonella sp. isolated were of the CTX-M family gene type. One strain of plasmid-mediated AmpC β-lactamase belonged to the CMY-2 family gene type. Our results thus showed that NA-resistant isolates were resistant to antimicrobial agents and confirmed the presence of a small number of isolates producing ESBL and AmpC β-lactamase.
In a nationwide antimicrobial susceptibility survey of 494 Nesseria gonorrhoeae isolates collected from February 2008 to December 2009 in 3 regions of Japan, 112 (22.7％) were collected from western Japan (Kinki, Chugoku, Shikoku, and Kyushu), 277 (56.1％) from mid-eastern Japan (Kanto), and 105 (21.1％) from eastern Japan (Tokai, Hokuriku, Koushinetsu, Tohoku, and Hokkaido). Resistance to ciprofloxacin (CPFX) was 72.8％, to penicillin G (PCG) 19.8％, and to tetracycline (TC) 18.2％. Intermediate resistance to CPFX was 1.8％, to PCG 73.7％, and to TC 43.7％. These results indicate that both types of resistance to the 3 agents were very high. Intermediate resistance to cefixime (CFIX) was 38.1％ and to cefozidim (CDZM) 13.4％. Resistance to CFIX was only 0.4％ and to CDZM 0％. Susceptibility to azithromycin was 96.6％, to ceftriaxone 99.8％, and to spectinomycin 100％. No significant difference in resistance was seen to different antimicrobial agent classes tested in the 3 regions, although intermediate resistance to CFIX in western Japan was significantly higher than in mid-eastern Japan.
A 70-year-old man with diabetes mellitus seen for fever, right chest pain, and right-lung field consolidation on chest X-ray was found in thoracoabdominal computed tomography (CT) to have variable-sized nodules in both lung fields and multiple low-density hepatic areas. On physical examination, his pulse was 145 beats per minute and blood pressure 92/68mmHg, indicating a preshock state. Laboratory tests showed elevated WBC of 15,200/μL, serum-C-reactive protein (CRP) of 34.4mg/dL, and a decreased platelet count of 16,000/μL. Suspecting liver abscesses complicated by aseptic pulmonary embolism, we immediately conducted percutaneous transhepatic abscess drainage (PTAD). Liver abscess blood culture and drainage fluidgrew the Klebsiella pneumoniae hypermucoviscosity phenotype, carrying the rmpA gene. Although the man had been in critical condition on admission, broad-spectrum antibiotics and PTAD treatment improved his clinical condition to where he could be discharged without problem.
Few case reports have been published on disseminated gonococcal infection in Japan. We report such a non-HIV case without typical skin rash. A 49-year-old Japanese man living in Thailand on business was seen for fever and multiple arthralgia after returning to Japan. Given the travel history, differential diagnoses included endemic viral infection such as human immunodeficiency virus (HIV), dengue fever, and chikungunya. Diagnosis was based on right-knee arthrocentesis, and synovial fluid culture followed by Neisseria gonorrhoeae polymerase chain reaction (PCR). The isolated strain was sensitive to penicillin. The man was treated with intravenous ceftriaxone and oral levofloxacin. Disseminated gonococcal infection should thus be considered when examining those with classical polyarthralgia symptoms even without a typical skin rash.
Legionella pneumonia tends to be severe and is known to be fatal. Introduction of the urinary Legionella antigen test and changes in the Infectious Disease Law have led to increased numbers of reports, and milder cases are now occasionally seen. We experienced three cases demonstrating mild respiratory infections and one case demonstrating nosocomial pneumonia associated by Legionella pneumophila serogroup 3. Case 1 showed multiple ground-glass opacities on HRCT and productive cough. Cases 2 and 3 showed abnormal findings on chest X-ray, and chest CT findings in both cases suggested chronic respiratory infection. Case 4 experienced fever and hypoxia, and pulmonary edema was noted on X-ray. All of them four cases were diagnosed with respiratory infections isolated L. pneumophila serogroup 3 by culture results, and three of them cases were treated in the outpatient clinic. Thus, milder cases of Legionella pneumonia may be encountered during routine care, and tests for Legionella should be performed in such cases.
A 73-year-old man admitted for near drowning was found after 24 hours of mild therapeutic hypothermia to have pneumonia. Blood gas analysis showed metabolic acidosis, hypercapnia, and hyponatremia. Chest X-ray and computed tomography （CT） showed bilateral mainly lower-lobe consolidation. After being treated with 13.5g of tazobactam/piperacillin and 1.0―1.25g of vancomycin per day for two weeks, the man recovered from his severe respiratory failure. Enterococcus faecium was isolated twice from sputum and raising the dose of vancomycin was effective, but it took 10 days to wean him from ventilator support. While this case may be rare, therapeutic hypothermia and near drowning together were considered predisposing factors in the severity of the pneumonia caused by E. faecium. The possibility of pneumonia due to vancomycin-resistant Enterococci should thus be considered in similar cases.